Rosenow Felix, Arzimanoglou Alexis, Baulac Michel
Interdiciplinary Epilepsy Center Marburg-Dept of Neurology, Philipps-University Marburg, Germany.
Epileptic Disord. 2002 Oct;4 Suppl 2:S41-51.
Considering that status epilepticus (SE) is a medical emergency associated with significant morbidity and mortality, there are surprisingly few evidence-based data to guide management decisions. The purpose of this review is to give an overview of the incidence and classification of SE and to summarise the recent developments in the treatment of generalized tonic clonic status epilepticus (GTCSE). These consist in two prospective randomised studies indicating that SE should be treated as soon as possible, even out-of hospital, by intravenous (IV) benzodiazepine. Lorazepam is probably the best choice for the initial therapy. However, the differences in efficacy as compared to diazepam, diazepam associated to phenytoin or phenobarbital were not significant. There is no Class I evidence to help us choose which drug to give in SE that is not responsive to the initial lorazepam. Traditionally, based on a long clinical experience, IV phenytoin is given as the second drug. Recently, phenytoin is being increasingly substituted by fosphenytoin, even though no formal, comparative tolerability studies have been performed to study this compound in GTCSE. Starting in the 1980's, the use of injectable valproic acid (IV VPA) has been reported in an increasing number of uncontrolled case series initiated by doctors, indicating relative easy use, relative good tolerability and suggesting that it may be efficacious. Finally, we have very little data concerning the treatment of SE refractory to a benzodiazepine and phenytoin. Despite this lack of data many centres today use midazolam or propofol rather than phenobarbital or pentobarbital in this setting because these compounds have short half-lives and are, therefore, easier to handle.
鉴于癫痫持续状态（SE）是一种与高发病率和死亡率相关的医疗急症，令人惊讶的是，几乎没有循证数据来指导管理决策。本综述的目的是概述SE的发病率和分类，并总结全身性强直阵挛性癫痫持续状态（GTCSE）治疗的最新进展。这些进展包括两项前瞻性随机研究，表明即使在院外，SE也应尽快通过静脉注射（IV）苯二氮䓬进行治疗。劳拉西泮可能是初始治疗的最佳选择。然而，与地西泮、与苯妥英或苯巴比妥联用的地西泮相比，其疗效差异并不显著。对于对初始劳拉西泮无反应的SE，没有I类证据帮助我们选择使用哪种药物。传统上，基于长期的临床经验，静脉注射苯妥英作为第二种药物使用。最近，苯妥英越来越多地被磷苯妥英取代，尽管尚未进行正式的比较耐受性研究来研究该化合物在GTCSE中的情况。从20世纪80年代开始，越来越多由医生发起的非对照病例系列报告了注射用丙戊酸（IV VPA）的使用，表明其使用相对简便、耐受性相对良好，并提示其可能有效。最后，关于对苯二氮䓬和苯妥英难治的SE的治疗，我们的数据非常少。尽管缺乏数据，但如今许多中心在这种情况下使用咪达唑仑或丙泊酚而非苯巴比妥或戊巴比妥，因为这些化合物半衰期短，因此更易于处理。
